Adult ADHD: Overdiagnosed? Underdiagnosed? Or Both?

A March 12, 2014 New York Times article indicated that the number of adults who were prescribed medication for ADHD has doubled in the last four years.

According to the writer Alan Schwartz, “Some experts said the report provided the clearest evidence to date that the disorder is being diagnosed and treated with medication in children far beyond reasonable rates, and that steeply rising diagnoses among adults might portend similar problems. These drugs can temper hallmark symptoms like severe inattention and hyperactivity but also carry risks like sleep deprivation, appetite suppression and, more rarely, addiction and hallucinations.” [my emphases added]

The public’s perception of over-diagnosis of ADHD goes back decades, so the concerns expressed in the article are nothing new. But many experts do not agree with this take on things. Dr. Lenard Adler of NYU is quoted by Schwartz as saying. “We still know that a majority of adults with ADHD are untreated.” And the DSM-5, released in May 2013, actually reduced the number of symptoms that adults need to exhibit regarding inattention, impulsivity, and hyperactivity, in order to qualify for a diagnosis of ADHD. The DSM-5 is most widely used manual of psychiatric and other related disorders among mental health professionals and medical providers, and so it has considerable sway over how ADHD diagnosis is implemented.

So what is going on here, is adult ADHD over-diagnosed or under-recognized?

Well, like many things in life, the answer lies in the eyes of the viewer. The question is a curious one though, since the concept of adult ADHD has only really been seriously considered in perhaps the last 15-20 years. Before that ADHD was really regarded as a disorder of childhood and perhaps sometimes adolescence, but not adulthood.

As a sometimes non-linear thinker (perhaps due to my left handedness), I actually think it is possible for ADHD to be over-diagnosed in some people (who don’t have the disorder) AND under-diagnosed in others who actually do have the disorder. Let me explain this a bit more.

Overdiagnosed?

From my clinical experiences, I feel that adult ADHD might be over-diagnosed for some of the reasons provided in the New York Times article involving, for instance, imperfect accuracy of self-reported symptoms and experiences. However another issue that I feel contributes to this situation (speaking only for myself here) is that we providers don’t often do enough digging and confirming to verify the diagnosis of ADHD such that it is reliably confirmed.

If It Walks Like a Duck…

You see, the symptoms of ADHD are similar in some ways to symptoms causes by a range of other conditions that also impact attention, impulse control, and the like. These include depression, some forms of anxiety, head injuries, metabolic imbalances, thyroid dysfunction, some seizure disorders, and on and on. The bottom line is that ADHD does not alone cause impulsivity and inattention; many things do. ADHD however is developmental in nature, unlike many of these other challenges, and so a detailed history of ADHD symptom onset and persistence must be taken, to adequate clarify if ADHD is really part of the picture. If you want to get the diagnosis right, a 10-item survey or a two minute interview without a patient history just isn’t going to cut it.

Shortcuts

Another interesting phenomenon in the diagnosis of ADHD—as well as many other DSM-5 conditions—involves providers taking shortcuts or looking for so-called “cardinal symptoms” to quickly confirm the presence of ADHD. Used correctly, the DSM-5 actually requires that a number of symptoms from clusters of problems be endorsed before the diagnosis can reasonably be given. It also required that other conditions that can also account for these symptoms be adequately ruled out.

What some providers tend to do is to just look for two, three, or maybe four supposed “tell-tale” signs of the disorder and then to go with the diagnosis of ADHD well before the accepted DSM-5 standard for the condition has been met. This saves time and allows everyone to feel relief with an answer. But it is often wrong because other factors have not been completely ruled out, and a developmental basis for the symptoms has not been established. In actuality a combination of symptom endorsements, a detailed personal history, and objective cognitive tests sensitive to the kinds of impairments and weaknesses common in ADHD would all be ideal for establishing the diagnosis.

The issues of short cuts and inaccurate ADHD diagnoses appear to be not just an American thing. A 2012 study in Germany by Bruchmueller and colleagues showed that a large group of mental health providers had a bias toward diagnosing ADHD in boys more than in girls, with a greater tendency to abandon the DSM-5 criteria when diagnosing boys with ADHD. The study also found that this bias in over-diagnosis of ADHD occurred more often among male professionals than in females.

Finally, I should point out that diagnosing ADHD is often a difficult task. ADHD in adults frequently co-occurs with other conditions, such as depression, anxiety, learning disabilities, and conduct disorders, and so it can be quite tricky to tease out or confirm with these other problems also present.

Underdiagnosed?

So you might conclude from the prior passage that I think that ADHD is over-diagnosed and too many American adults are on ADHD medication. Well, not exactly.

You see, the problem with a lot of the media coverage on ADHD is that it tends to suggest (even if inadvertently or indirectly) that ADHD is not legitimate, an excuse, a first-world justification. And those messages have been learned by all of us, even those who really need help with the disorder. I mean, who has not heard that opinion about ADHD at some point in their lives?

Nearly every client I have worked with in an assessment or therapeutic context who received a valid diagnosis of ADHD has expressed this view at some point. They describe their diagnosis as “an excuse,” “fake,” “a sham,” “really about laziness,” and so on. The skepticism about ADHD in children and adults is widespread, despite a massive degree of clinical and research literature in support of the diagnosis and its treatment.

So while some of the points raised in the article on ADHD medication have merit with respect to concerns about over-medication and over-diagnosis of the disorder, a potential fallout of this and similar types of media reports on ADHD is that people who really do have ADHD will deny it exists, or at least that it exists in themselves. They are discouraged from attending to something that is both destructive to them and highly treatable.

Individuals with untreated adult ADHD toil unnecessarily in their marriages, their jobs, and their schools—I have seen it many times—because they do not avail themselves to being assessed for, and if applicable, treated for adult ADHD. Shame, low self-esteem, and even depression all frequently stem from a misunderstanding of their ADHD. They don’t know or don’t accept that they have it. So what can be done?

Parting Thoughts

The issues of adult ADHD diagnosis and treatment concerns are not going to be solved in a 1,400 word blog. They are complex and involve a range of other social, biological, and emotional factors not even mentioned here.

My own humble opinion is that adult ADHD is often missed (under-diagnosed) in those who do have it and are negatively impacted by it, and that it is often over-diagnosed in those who don’t have it due to suboptimal assessment methods by clinicians and providers.

If anything can be done, my suggestion for change is for clinicians to take more time to adequately assess for adult ADHD, that they take a continuing education class or read a book on what adult ADHD truly is if they are not familiar with it, and that the self-reported symptoms being understood within the context of a clinical history and the DSM-5 criteria, with follow up verification by a specialist who is knowledgeable about adult ADHD and who can provide adjunct cognitive test results to support the diagnosis of adult ADHD. And then if it really is there, to treat it with a combination of medication and effective therapy methods.

I think you're right. It's a fairly common ADHD trait to see multiple perspectives, such as this - so it makes sense. Another group I would add to your under-diagnosed would be the intelligent/gifted group. As possibly people who get the most frustrated with themselves, I think we're more open to presenting as if we have depression. My doctor wanted to treat the ADHD first (and guidelines suggest the opposite) because he felt my depression was situational because of having undiagnosed ADHD.

Another factor is the 'newness' of the inattentive sub-type. It's just as real - I sometimes say it's like having the 'classic ADD kid' inside our head rather than being that kid to others. It is going to increase diagnosis when you create a whole new 'half' to the disorder. In addition, all the people like me who got missed growing up because it wasn't being considered as a possibility are finding out now well into adulthood. There needs to be an allowance in figures to play 'catch-up'.

Unfortunately if diagnosed with depression, and handed an SSRI - our deficiencies are exacerbated since norepinephrine and dopamine are dampened when taking these medications - we just care less, because serotonin lets us detach. It can feel close enough to psychopathy the way we experience feelings sometimes - SSRIs can push that to extremely obvious levels.

It's a disorder that needs an overhaul and I hope one day to be involved in giving it one!

I agree with your appreciation and miss some facts that also lead to undertreatment of those who should be treated.
First, the legal procedure against Ciba and later Novartis intending to prove that this diagnosis was just made to sell drugs persistently leaves a doubt about ADHD beeing a good diagnosis, even 20 yeras later.
Second the DSM criterion that one should exclude ADHD if symptoms are better explained par another condition lets a big margean for subjective apreciation about what a better explanation is:
Better corresponding to the present symptoms? to the course of illness? to the learnded knowledge? better for finding new treatement opportunities?
Let's add that by the high number of comorbid conditions, the necessitiy and usefullness of an additional diagnosis may be questionnable.
So at least in our country (Switzerland) I encounter much resistance to diagnose such a "hot" diagnosis that does not fit with psychoanalytic thinking nor respond well to classical behavioral or systemic methods.
I am astonished how poorly interested my collegues are in a condition that affects about 20 % of their patients!
Add to this the persistend desinformation from Scientology. The power of their impact is so strong, that one may wonder if psychiatrist are mainly oriented by scientific findings.
You claim for better diagnostic practices. I believe diagnosis to be clinical and agree that it shoould be done carefully.

DSM V defines severity by a number of symptoms and not by the impact they have on everyday life. I think, this would be necessary to say if treatment indication is accurate ore not.
Krause and Krause have published a 10-point list (in german) for such purpose.
Thank you for your aricle
C.Kaufmann